CMS-10891 Application for Medicare Savings Programs (MSP) (English

Medicare Savings Program (MSP) Application Instructions
Use this application to see if you or you and your spouse qualify for the state to pay your Medicare premiums and/or
cost-sharing. This is NOT an application for other benefits such as long-term services and supports. If you would like
to apply for other Medicaid coverage or need help completing any part of this form, contact your local Medicaid
office - https://www.medicaid.gov/about-us/beneficiary-resources/index.html#statemenu
There are three types of Medicare Savings Programs (MSPs):
Qualified Medicare Beneficiary (QMB): the state pays your Medicare Part A and/or Part B premiums and cost
sharing (deductibles, co-insurance and copays). If you qualify for QMB, you automatically qualify for Extra Help to
pay your Medicare Part D drug coverage costs.
Specified Low-Income Medicare Beneficiary (SLMB): the state pays your Medicare Part B premiums, and you
automatically qualify for Extra Help to pay your Medicare Part D drug coverage costs.
Qualifying Individual (QI): the state pays your Medicare Part B premiums, and you automatically qualify for Extra
Help to pay your Medicare Part D drug coverage costs.
The state will decide if you qualify (and if your spouse qualifies, if your spouse is applying too). If you're approved
for an MSP, your Part B premium will no longer be deducted from your Social Security, Railroad or Civil Service
retirement benefits, and you'll automatically be enrolled in Extra Help to pay your Medicare Part D premiums and cost
sharing for covered prescription drugs. Contact your Medicaid office if you are not enrolled in the Extra Help benefit.
Estate recovery does not apply to any help you get for payment of Medicare premiums or cost-sharing. That means
you will NOT need to pay back any help you receive through a Medicare Savings Program.

What you may need to apply
You may need to provide copies of documents to confirm some information, including:
• Proof of income (like retirement or disability benefits or pay stubs)
• Proof of assets (like bank statements or life insurance policies)
• Proof of Medicare
• For non-citizens, proof of eligible immigration status (like a, green card, passport or other documentation from
the Department of Homeland Security)
• Proof of where you live (like a rent receipt, utility bill, or state issued ID card)
If you need more room to write, attach additional pages.

Ways you can apply
•
•
•
•
•

Complete an online application at___________________
Mail this paper application to ____________
Fax this application to ____________
Visit your [state agency] office at ____________
Call your [state agency] for assistance at ____________

Keep a copy of the application for your records.

What happens next?
Your Medicaid agency will review your application. You should get a response about your eligibility within 45 days.
If you don’t get a response within 45 days, contact your Medicaid agency.

Get help with questions about Medicare Savings Programs
For questions about Medicare Savings Programs or your Medicare benefits, contact your local State Health Insurance
Assistance Program (SHIP). Find their contact information by calling 877-839-2675 or visiting
https://www.shiphelp.org/.

Application for Medicare Savings Programs
Personal Information

Applicant – List your name as it appears on your Medicare card
Last name

First name

Middle name

Address where you live

City

State

ZIP code

Mailing address (if different)

City

State

ZIP code

Primary phone:

Alternate phone (optional):

Email address (optional)

Marital status:

Citizenship status:
Are you a U.S. citizen?

□ Not married (single/divorced/widowed)
□ Married, living with spouse
□ Married but separated from spouse

□ Yes □ No

If not, do you have eligible immigration status? □ Yes ( Please complete the information below) □ No
Alien number, I-94 number or document Date status was granted Date you entered
Country of origin
ID number and document type
the U.S.
Are you, or your spouse or parent, a veteran or an active-duty member of the U.S. military? □ Yes

Is your spouse a U.S. citizen (if your spouse is also applying for an MSP)? □ Yes □ No
If not, do they have eligible immigration status? □ Yes ( Please complete the information below)
Alien number, I-94 number or document Date status was granted Date you entered
ID number and document type
the U.S.

□ No

□ No
Country of origin

Household Members

Include your spouse living in the same household. Include relatives living in the same household who are dependent on either
you or your spouse for at least half of their financial support. If you need more room to write, attach additional pages.
Name (last, first, middle)

Relationship
to you

Date of
birth

Self

□ Yes □ No

Spouse

□ Yes □ No

Other
(specify)
Other
(specify)

Social Security number
(if applying for MSPs)

Applying for MSP
benefits?
`

Optional

N/A
Optional

N/A

Medicare Coverage Information
Do you have Medicare?
Self

□ Yes □ No

Spouse

□ Yes □ No

Type of coverage

Medicare Number

□ Part A
□ Part B
□ Part A
□ Part B

Other Health Insurance Information

(such as employer, Medigap, Tricare, VA health benefits)

Policy holder

Insurer

Type of insurance

Policy number

Income
List any income you or your spouse receive. Provide the amount of income before any deductions such as taxes or insurance
premiums are taken out. Types of income include, but are not limited to:

• Social Security Benefits
• Supplemental Security
•
•

Income (SSI)
Railroad Benefits
Civil Service Retirement Benefits
Who gets this income?

•
•
•
•
•

Public Assistance
Unemployment Insurance
Workers Compensation
Veterans Benefits
Alimony Payment

Type of income
(such as employer
or Social Security)

•
•
•
•
•

Wages from a job
Commissions
Self-employment
Dividends and Interest
Rental Income

What amount?
$
$
$
$
$
$
$

How often is it received?
(weekly, every two weeks,
monthly)

Assets
If you or your spouse has assets, list the type of asset, who owns the asset and if the asset is owned individually or jointly.
Assets include, but are not limited to:
• Cash
• Mutual Funds
• Individual Retirement Accounts (IRAs)
• Checking Account
• Savings Bonds
• Burial Funds
• Savings Account
• Stocks
• Homes or lands that you own
• Money Market Accounts • Certificates of Deposit (CD)
(excluding primary residence)
Type of asset

Name of owner(s)

Ownership

Current value

□ Individual
□ Joint
□ Individual
□ Joint
□ Individual
□ Joint
□ Individual
□ Joint
□ Individual
□ Joint
□ Individual
□ Joint
□ Individual
□ Joint
□ Individual
□ Joint

$
$
$
$
$
$
$
$

Do you or your spouse own any vehicles (car, truck, boat, motor home, motorcycle, camper, and/or trailer)?
If yes, please list below and indicate which is your primary vehicle:
Name of owner(s)

Ownership

□ Individual
□ Joint
□ Individual
□ Joint
□ Individual
□ Joint
□ Individual
□ Joint

Type of
vehicle

Year

Make/Model

Amount
owed

Value
$

$

$

$

$

$

$

$

Do you and/or your spouse have whole life insurance policies with a combined face value above $1,500? If yes, please list
below:
Name of insurance
Need help finding
Insured Person
Face value
Cash value
company/policy number
the value of policy?

□ Yes □ No

$

$

□ Yes □ No

$

$

Read Carefully Before Signing
I understand that:
• I must report any changes in my situation to the Medicaid agency right away. Late reporting may cause
incorrect benefits.
• My situation is subject to verification by the Medicaid agency or other state or federal agencies.
• The Medicaid agency may ask me to show proof if I’m eligible. The Medicaid agency may help me get the
proof or contact other people or agencies for it.
• By submitting this application, I am authorizing the state Medicaid agency to contact my life insurance
company on my behalf.
• By asking for and receiving medical care benefits, I assign to the state all rights to any medical support and to
any third-party payments for medical care.
• If I’m found eligible for a Medicare Savings Program, I will not be subject to estate recovery for any help I
get to pay my Medicare premiums, deductibles, or coinsurance.
You’ll get an Eligibility Notice in the mail after we process your application. If you don’t agree with what you
qualify for, you can ask for an appeal. Review your Eligibility Notice to find appeals instructions specific to each
person in your household who applies for coverage, including how many days you have to request an appeal. Here’s
important information to consider when requesting an appeal:
You can have someone request or participate in your appeal if you want to. That person can be a friend, relative,
lawyer, or other individual. Or, you can request and participate in your appeal on your own.
To ask for an appeal, call us at 1-800-XXX-XXXX (TTY: 1-800-XXX-XXXX). Or, go to [medicaid.state.gov] to
get an appeals form. Or, you can write your own letter and send or bring it to us at the State Medicaid Agency, 321
Any Road, Any City, Any State 00100.
Declaration and Signatures
I have read and understood the information in this application. I declare, under penalty of perjury, the information I
have given in this application is true, correct, and complete to the best of my knowledge.
Applicant/representative signature:

Date:

Spouse signature (if applicable):

Date:

Representative name:

Representative phone number:

Representative mailing address:

Representative email address:

Relationship to applicant:

You have the right to get your information in an accessible format, like large print, Braille, or audio. You also
have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/aboutus/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information.
TTY users can call 1-877-486-2048.

Optional: (Providing this information won’t impact eligibility.)
SELF: check all that apply
If Hispanic/Latino ethnicity
□ Mexican □ Mexican American
Race
□ White
□ Black or African American

□ Chicano/a □ Puerto Rican □ Cuban □ Other____________

□ American Indian or Alaska Native □ Filipino □ Vietnamese
□ Guamanian or Chamorro
□ Asian Indian
□ Japanese □ Other Asian
□ Samoan
□ Chinese
□ Korean □ Native Hawaiian □ Other Pacific Islander
□ Other________________

Choose one response.
Sex assigned at birth (may be found on your birth certificate)

□ Female □ Male □ Other______________ □ Not sure □ Prefer not to answer

Current gender:

□ Female □ Male □ Transgender female □ Transgender male □ A different term_________ □ Not sure □ Prefer not to answer

Sexual Orientation:

□ Bisexual □ Lesbian or gay □ Straight (not lesbian or gay) □ A different term __________ □ Not sure □ Prefer not to answer

Optional: (Providing this information won’t impact eligibility.)
SPOUSE: check all that apply
If Hispanic/Latino ethnicity
□ Mexican □ Mexican American
Race
□ White
□ Black or African American

□ Chicano/a □ Puerto Rican □ Cuban □ Other____________

□ American Indian or Alaska Native □ Filipino □ Vietnamese
□ Guamanian or Chamorro
□ Asian Indian
□ Japanese □ Other Asian
□ Samoan
□ Chinese
□ Korean □ Native Hawaiian □ Other Pacific Islander
□ Other________________

Choose one response.
Sex assigned at birth (may be found on your birth certificate)

□ Female □ Male □ Other______________ □ Not sure □ Prefer not to answer

Current gender:

□ Female □ Male □ Transgender female □ Transgender male □ A different term_________ □ Not sure □ Prefer not to answer

Sexual Orientation:

□ Bisexual □ Lesbian or gay □ Straight (not lesbian or gay) □ A different term __________ □ Not sure □ Prefer not to answer